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42 Diagnostic EMQs
N. Schamberg disease
O. Sweet’s syndrome
For each of the following, what is the MOST likely diagnosis?
1. A 5-year-old presents with a lesion on her hand which has been present for the
past four weeks and has not gone away. She has not been scratching at it and
it does not seem to bother her. On examination there is a esh-coloured raised
ring-like lesion over the dorsum of the right PIP of the index nger. The surface
of the lesion is smooth and the centre is slightly depressed.
2. A 67-year-old woman presents with a painful ulcerating lesion over her
left shin. She explains that she pricked her shin on a rose bush while gar-
dening, the next day noticed a small red bump which rapidly developed
into an ulcer. On examination there is an ulcer on her shin with a viola-
ceous border.
3. A 60-year-old man presents with tender bumps on his left hand which are pro-
gressively increasing. On examination there are multiple red-purple nodules
and vesicles on the dorsum of his left hand and thumb. On palpation the lesions
are solid. Abiopsy is performed which reveals dense neutrophilic inltration in
the papillary dermis without evidence of vasculitis.
4. A 26-year-old woman attends with a pruritic rash affecting her right wrist. On
examination there are several purple, at topped, shiny, polygonal plaques over
her right wrist. The plaques are crossed by ne white lines.
See pages 51–52 for answers.
INFLAMMATORY DISORDERS 2
A. Chronic supercial scaly dermatitis
B. Doucas–Kapetanakis eczematid-like purpura
C. Erythema multiforme
D. Erythema nodosum
E. Granuloma annulare
F. Granuloma faciale
G. Lichen aureus
H. Lichen planus
I. Morphea
J. Pityriasis lichenoides et varioliformis acuta
K. Pityriasis rosea
L. Purpura annularis telangiectodes
M. Pyoderma gangrenosum
N. Schamberg disease
O. Sweet’s syndrome
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Dermatology 43
For each of the following, what is the MOST likely diagnosis?
1. A 19-year-old woman attends your clinic complaining of a widespread non-
pruritic rash which has been present for the past two days. On examina-
tion she has multiple scaly oval shaped lesions across her chest and back
which resemble a Christmas tree in distribution. She attended your clinic
two weeks ago because she noticed a single large circular lesion on her
abdomen.
2. A 14-year-old girl attends your GP clinic concerned about a discoloration over
the right side of her forehead which has been present for the past six months.
She denies any associated pain or itch. On examination there is a linear, hyper-
pigmented patch over the right forehead extending from the lateral eyebrow to
her hairline.
3. A 25-year-old woman presents to your clinic with painful red nodules over her
anterior shins. You saw her two weeks ago for tonsillitis which you treated
with penicillin. On examination there are several tender erythematous nodules
measuring between 3–5cm in diameter over the anterior surfaces of bilateral
shins.
4. A 32-year-old man presents with pruritic lesions on his hands and feet
which have now spread onto his torso. He explains that three days ago he
had ulceration in his mouth and around his lip which is still present. On
examination you note numerous small target lesions on his hands, feet and
torso.
See page 52 for answers.
SKIN LESIONS 1
A. Actinic keratoses
B. Basal cell carcinoma
C. Chondrodermatitis nodularis helicis
D. Dermatobroma
E. Dermatobrosarcoma protuberans
F. Gorlin syndrome
G. Invasive squamous cell carcinoma
H. Keratoacanthoma
I. Merkel cell carcinoma
J. Myxoid cyst
K. Pilar cyst
L. Polymorphous light eruption
M. Pyogenic granuloma
N. Solar lentigo
O. Squamous cell carcinoma in situ
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44 Diagnostic EMQs
For each of the following, what is the MOST likely diagnosis?
1. A 36-year-old woman presents with a lump on the crown of her head. The lesion
has been present for the past ve years but is now pruritic and has been worsen-
ing over the past 4 weeks. On examination there is a cystic structure measuring
2cm x 2cm without a central punctum.
2. A 66-year-old is concerned about a rapidly growing lesion on his nose. On
examination there is a 2.5cm well dened, round, erythematous lesion with a
central hyperkeratotic plug.
3. A 71-year-old farmer is concerned about a scaly rash on his face, forehead and
hands. He explains that he initially had small scattered lesions which have grad-
ually increased in size and number. On examination there is excessively dry
appearing skin with multiple red-coloured scaly lesions on the face, forehead
and hands. The lesions are tender to touch. A “strawberry” pattern appearance
is evident on dermoscopy.
4. A 54-year-old farmer presents with a ve-month history of a lesion on his right
cheek which he is concerned about. On examination there is a well-dened
pearly, nodular lesion with telangiectasia on its surface.
5. A 34-year-old is concerned about a painless lump on her left shin that has been
present for the past 12 months. She explains that she is embarrassed by it and
cannot wear skirts as a result, she has also caught it a few times while shaving
her legs. On examination there is a solitary rm red-brown nodule on the left
shin, pinch sign is positive.
6. A 61-year-old presents with a nine-month history of a slowly enlarging lesion
on her right forearm. On examination there is an erythematous plaque with an
irregular border measuring 3cm in diameter. There is scaling on the surface of
the lesion. Dermoscopy reveals irregular clusters of glomerular vessels.
See pages 52–53 for answers.
SKIN LESIONS 2
A. Actinic keratoses
B. Basal cell carcinoma
C. Chondrodermatitis nodularis helicis
D. Dermatobroma
E. Dermatobrosarcoma protuberans
F. Gorlin syndrome
G. Invasive squamous cell carcinoma
H. Keratoacanthoma
I. Merkel cell carcinoma
J. Myxoid cyst
K. Pilar cyst
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Dermatology 45
L. Polymorphous light eruption
M. Pyogenic granuloma
N. Solar lentigo
O. Squamous cell carcinoma in situ
For each of the following, what is the MOST likely diagnosis?
1. A 26-year-old woman presents to your clinic concerned about a painless red
lump on her right cheek. She gave birth one month ago and rst noticed the
lump in her nal trimester of pregnancy. On examination there is a shiny red
eshy nodule over her right cheek which measures 1cm in diameter.
2. A 37-year-old man presents with a lesion on the left side of his forehead. He
explains that it bleeds easily even after gentle scraping. On examination there is
a soft, dome shaped, red coloured nodule without hyperkeratosis.
3. A 26-year-old woman is concerned about a rash she has been suffering from.
She explains that she has a rash across her face, chest and arms which develops
every spring. On examination she has crops of pink papules across her cheeks,
the V of her neck and her upper limbs.
4. A 46-year-old Caucasian woman presents to your clinic as she is concerned
about a brown patch which has developed over the past 12 months on the dor-
sum of her right hand. On examination there is a well-dened, round, sym-
metrical, macular tan-brown lesion on the dorsum of her right hand.
5. A 31-year-old man presents to your clinic complaining of a four-month history
of right ear swelling and discomfort which awakens him at night. On examina-
tion there is a rm, solitary, oval shaped lesion over the apex of the helix of the
right pinna. There is associated central crust and surrounding erythema.
See page 53 for answers.
PIGMENTATION DISORDERS 1
A. Acanthosis nigricans
B. Albinism
C. Erythrasma
D. Melasma
E. Mongolian blue spot
F. Naevus anaemicus
G. Neurobromatosis – type 1
H. Peutz–Jeghers syndrome
I. Pityriasis alba
J. Pityriasis versicolor
K. Poikiloderma of Civatte
L. Seborrheic keratosis
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46 Diagnostic EMQs
M. Supercial spreading melanoma
N. Tinea nigra
O. Trichomycosis axillaris
P. Tuberous sclerosis
Q. Vitiligo
For each of the following, what is the MOST likely diagnosis?
1. A 32-year-old type 2 diabetic male presents to your clinic concerned about a
rash in his right armpit which has been present for the past six months. On
examination there is a well-dened brown patch in the right armpit with ne
scaling. Wood’s lamp examination demonstrates coral-pink uorescence.
2. A 43-year-old woman presents with a 12-month history of red discoloration
over her upper chest and neck. She reports that at times there is itching and
burning sensations in the affected areas. She has no signicant medical history
and does not take any medication. On examination there are symmetrical, red
coloured, atrophic patches over her upper chest and the sides of her neck with
sparing of the submental area.
3. A 22-year-old man recently returned from a two-week holiday in Southern
Spain and has noticed discoloration on his trunk and neck. On examination
there are patches across the trunk and neck which are paler than surrounding
tanned skin. The patches have a bran like scale.
4. A 3-year-old child presents with his parents who are concerned about hypopig-
mented lesions they have noticed on his body. He has a history of developmental
delay and recurrent seizures for which he is seeing a paediatrician. On examina-
tion there are two hypomelanotic macular lesions on his chest and two on his
back which are ash leaf–shaped.
5. A 36-year-old woman presents to your GP clinic with a worsening non-pruritic,
non-painful, brown patch on her right hand. On examination there is an asym-
metrical brown patch on her right palm which is slightly scaly. Abiopsy is
performed which demonstrates multiple short, segmented hyphae and spores in
the stratum corneum which are brown coloured with H&E staining.
See page 53 for answers.
PIGMENTATION DISORDERS 2
A. Acanthosis nigricans
B. Albinism
C. Erythrasma
D. Melasma
E. Mongolian blue spot
F. Naevus anaemicus
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Dermatology 47
G. Neurobromatosis – type 1
H. Peutz–Jeghers syndrome
I. Pityriasis alba
J. Pityriasis versicolor
K. Poikiloderma of Civatte
L. Seborrheic keratosis
M. Supercial spreading melanoma
N. Tinea nigra
O. Trichomycosis axillaris
P. Tuberous sclerosis
Q. Vitiligo
For each of the following, what is the MOST likely diagnosis?
1. A 3-year-old attends with his mother as she is concerned about a non-pruritic
discoloration she has noticed on his face. On examination there are multiple cir-
cular hypopigmented patches across his face measuring between 0.5 and 1cm
in diameter.
2. A 36-year-old woman presents with dark brown discolouration across her face
which has been present for the past four months. She is currently 36 weeks’
gestation and has no signicant medical history. On examination there are
symmetrical, bilateral dark brown macules with irregular borders on the malar
cheeks and forehead.
3. A 39-year-old woman presents to your clinic concerned about a lesion she has
had on her left forearm. She explains that it has been there for the past two years
and has gradually increased in size and she is embarrassed by its appearance.
She explains that it feels as though the lesion is “stuck onto” the surface of her
skin and it is almost as if she could just “pick it off” with her ngernail. On
examination there is a solitary 15mm diameter raised brown plaque like thick-
ening on her left forearm with a waxy surface.
4. A 45-year-old woman attends your clinic with a rash in bilateral axillae and
groins. She is a type 2 diabetic and has a history of PCOS. On examination
there is a symmetrical, dark brown, velvety rash in the affected areas.
5. A 34-year-old woman presents to your clinic with multiple worsening depig-
mented areas on her trunk and limbs. She has a history of pernicious anaemia
and had her last B12 injection three months ago. On examination there are sev-
eral well dened milky white patches across her body.
See pages 53–54 for answers.
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48 Diagnostic EMQs
ANSWERS
Childhood infections 1
1. K. Scarlet fever
This is a bacterial illness caused by group Astreptococcus. This patient has
typical examination ndings.
2. B. Erythema infectiosum
Also known as fth disease, this condition is caused by parvovirus B19.
3. C. Hand, foot and mouth disease
This is a very infectious viral illness caused by the Coxsackie virus.
4. A. Chicken pox
This highly contagious condition results in an itchy, blistering rash and is caused
by the varicella zoster virus.
5. F. Molluscum contagiosum
This is a contagious condition caused by the molluscum contagiosum virus.
6. H. Rheumatic fever
This patient has had a streptococcal infection recently and now presents with a
combination of major and minor criteria for diagnosis of acute rheumatic fever.
Childhood infections 2
1. D. Kawasaki syndrome
This is an acute febrile illness in children which affects the small- and medium-
sized blood vessels, particularly the coronary arteries.
2. E. Measles
This is a highly contagious condition caused by the measles virus. This was
once a very widespread condition but in countries where measles is part of the
vaccination schedule the incidence is very low.
3. I. Roseola infantum
This condition results from infection with human herpes virus 6. It is characterised
by high fevers lasting between three to ve days followed by rash development.
4. L. Staphylococcal scalded skin syndrome
This is a serious skin infection which develops as a result of a toxin produced
by a staphylococcal infection.
5. G. Mumps
This condition is caused by an RNA paramyxovirus. Patients typically present
with a prodrome of low-grade fever, myalgia, headaches and anorexia followed
by swollen parotid glands.
Skin reactions
1. C. DRESS syndrome
This patient has had a severe drug reaction to lamotrigine, she also has eosin-
ophilia and systemic symptoms. This condition usually appears two to eight
weeks after starting an offending medication.
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Dermatology 49
2. G. Porphyria cutanea tarda
This is the most common type of porphyria and is due to a defect in a liver
enzyme called uroporphyrinogen decarboxylase (UROD). Urine samples dem-
onstrate a characteristic coral coloured uorescence when placed under Wood’s
lamp.
3. A. Acute generalised exanthematous pustulosis
Also known as toxic pustuloderma, this is an acute drug reaction which is char-
acterised by development of pinhead sized, non-follicular pustules on erythem-
atous skin. The rash usually lasts for about ten days and then resolves by peeling
off.
4. F. Jarisch–Herxheimer reaction
This is a reaction which may be seen in individuals infected with spirochetes
who commence treatment with antibiotics. It occurs within 24hours of com-
mencement of treatment.
5. E. Fixed drug eruption
This is an oval shaped erythematous lesion which develops after taking the
offending drug. These usually recur at the same site after re-exposure to the
same drug.
6. H. Stevens–Johnson syndrome
This is a life-threatening skin condition which requires prompt treatment. Sul-
fonamides are a common cause of this reaction.
Hair
1. E. Hypertrichosis
This condition involves excessive hair growth beyond what is normal for gen-
der, age and race. It should not be confused with hirsutism which is hair growth
in women which follows a male pattern of distribution.
2. A. Alopecia areata
This is an autoimmune condition which can lead to hair loss. The hair loss
occurs in small patches. This patient has typical examination ndings.
3. H. Telogen efuvium
This is a common cause of temporary hair loss due to excessive shedding of
telogen hair. Acute episodes are commonly caused by a signicant physical
stressor.
4. J. Trichotillomania
This is a psychological disorder which involves an urge to pull at hair from vari-
ous areas of the body.
5. D. Hirsutism
This condition involves male pattern hair growth which occurs in women. It
should not be confused with hypertrichosis, a condition which involves exces-
sive hair growth beyond what is normal for gender, age and race.
6. I. Tinea capitis
Also known as ringworm of the scalp, this is a rash which is caused by a fungal
infection.
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50 Diagnostic EMQs
Nails 1
1. Q. Subungual hematoma
This results from bleeding under the nail and is usually secondary to trauma or
repetitive micro trauma to the affected nail.
2. O. Panchyonychia congenita
This patient has typical examination ndings including palmoplantar kerato-
derma and nail thickening.
3. P. Psoriasis
This patient has typical nail ndings associated with psoriasis; the skin ndings
are also consistent with this diagnosis.
4. K. Myxoid cyst
These are benign growths which affect the digits but most commonly occur on
the ngers.
5. B. Acute paronychia
This is a rapidly developing infection of the nail fold which is commonly associ-
ated with trauma.
Nails 2
1. N. Onycholysis
This is a common nail condition in which the nail separates from the nail bed
giving a characteristic appearance in which the distal nail appears grayish-
white in color.
2. D. Candida onychia
Diabetics and immunocompromised individuals are at greater risk of this
condition.
3. M. Onychogryphosis
This is a condition more commonly seen in the elderly and usually results from
poor footwear.
4. A. Acrolentiginous melanoma
This condition usually affects the thumb or great toe and is unrelated to sun
exposure. Patients typically present with a narrow-pigmented band which wid-
ens and becomes more irregular. Hutchinson sign describes extension of the
pigmentation to involve the skin of the nail fold.
5. E. Chronic paronychia
This condition is diagnosed clinically and is characterised by symptoms lasting
greater than six weeks. Chronic paronychia results from irritant dermatitis.
Nail signs of systemic illness
1. A. Apparent leukonychia
This patient has Terry type nails which can be associated with hepatic disorders.
2. C. Koilonychia
This describes a thin spoon shaped nail, which is a common nding in iron
deciency anaemia.
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Dermatology 51
3. B. Beau’s lines
These are transverse depressions which result from disruption of nail growth.
These are a common nding in patients undergoing chemotherapy.
4. D. Periungual broma
Also known as Koenen tumors, these are benign lesions affecting the nails of
individuals with tuberous sclerosis.
5. H. Yellow nail syndrome
This is a nail condition in which there is a yellow discoloration of the nails and
apparent growth cessation. It is commonly associated with pleural effusions and
lymphoedema, the exact cause is unknown.
Dermatitis 1
1. H. Lichen simplex chronicus
This is a chronic form of dermatitis which results from repeated scratching of
skin.
2. B. Asteatotic dermatitis
Also known as eczema craquele, this is a common form of dermatitis which
occurs as a result of dry skin.
3. K. Seborrheic dermatitis
This is a skin condition which causes red patches and scaling, it typically affects
areas with high sebum production.
4. A. Allergic contact dermatitis
This is a form of eczema which is caused by an allergic reaction as a result of
an allergen coming into contact with the skin. This patient has likely been re-
exposed to a substance to which they have been sensitised.
Dermatitis 2
1. F. Dyshidrotic eczematous dermatitis
Also known as vesicular hand dermatitis or pompholyx, this is a form of eczema
characterised by vesicle or bullae formation.
2. C. Atopic dermatitis
This is the most common form of inammatory skin disease in all patients.
This is a chronic condition and patients have periodic are-ups.
3. I. Nummular eczema
Also known as discoid eczema, this is a common form of eczema in which there
are well dened scattered coin-shaped eczematous plaques.
4. G. Irritant contact dermatitis
This is a form of dermatitis which is localised to the area which has been
exposed to the irritant. The hands are most commonly affected. Patients typi-
cally describe a burning, painful sensation rather than an itch as is seen in
allergic contact dermatitis.
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